Attitudes of doctors of medicine and dental medicine towards contacting patients via social networks

Background

As the use of social networking sites (SNSs) has greatly increased among health professionals, it is necessary to investigate their use of SNSs. The aim of this study was to identify the patterns of SNS use for contact with patients between medical doctors (MD) and doctors of dental medicine (DMD) in Croatia.

Methods

In collaboration with the Croatian Medical Chamber and the Croatian Chamber of Dental Medicine, a quantitative cross-sectional study was conducted on the use of SNSs and the attitudes of MDs and DMDs towards e-professionalism. Data were collected using online questionnaires. The data were analyzed using descriptive statistics.

Results

A total of 753 responses were processed, 507 (67,3%) MDs and 246 (32,7%) DMDs. DMDs were significantly more likely to visit patients or their family members’ profiles on SNSs (60,6% vs 33,3%, P < 0.001). The main reason for visiting a patient’s or family member’s profile is social communication, which is significantly more common among DMDs (46,3% vs 29,0%, P < 0.002). DMDs are significantly more likely to send friend requests from private SNS profiles to patients or their family members (15,0% DMDs vs 3,4% MDs, P < 0.001). Patients are much more likely to send friendship and connection requests on SNS to DMDs (91,1% DMDs vs 62,7% MDs, P < 0.001) who are also significantly more likely to accept these requests (76,8% DMDs vs 41,5% MDs, P < 0.001). MDs and DMDs would find the presence of e-professionalism guidelines useful (72,2% MDS vs 78,0% DMDs, P = 0.103).

Conclusions

The results show that DMDs are more open to communicating with patients via SNSs. Results showed a difference between MDs and DMDs in both directions - in sending requests to patients or their family members and in positive responses to their requests for connection. The findings point to the need to develop guidelines for health professionals regarding e-professionalism.

Key messages

• There are differences between MDs and DMDs toward communicating with patients using SNSs, DMDs being more open to the communication with patients.

• There is a need to develop guidelines for health professionals on e-professionalism with emphasis regarding how to professionally communicate with patients on SNSs.

Characterization of passive dosimeters in proton pencil beam scanning - A EURADOS intercomparison for mailed dosimetry audits in proton therapy centres

The lack of mailed dosimetry audits of proton therapy centres in Europe has encouraged researchers of EURADOS Working Group 9 (WG9) to compare response of several existing passive detector systems in therapeutic pencil beam scanning. Alanine Electron Paramagnetic Resonance dosimetry systems from 3 different institutes (ISS, Italy; UH, Belgium and IFJ PAN, Poland), ^natLiF:Mg, Ti (MTS-N) and ^natLiF:Mg, Cu, P (MCP-N) thermoluminescent dosimeters (TLDs), GD-352M radiophotoluminescent glass dosimeters (RPLGDs) and Al₂O₃:C optically stimulated dosimeters (OSLDs) were evaluate. Dosimeter repeatability, batch reproducibility and response in therapeutic Pencil Beam Scanning were verified for implementation as mail auditing system. Alanine detectors demonstrated the lowest linear energy transfer (LET) dependence with an agreement between measured and treatment planning system (TPS) dose below 1%. The OSLDs measured on average a 6.3% lower dose compared to TPS calculation, with no significant difference between varying modulations and ranges. Both GD-352M and MCP-N measured a lower dose than the TPS and luminescent response was dependent on the LET of the therapeutic proton beam. Thermoluminescent response of MTS-N was also found to be dependent on the LET and a higher dose than TPS was measured with the most pronounced increase of 11%. As alanine detectors are characterized by the lowest energy dependence for different parameters of therapeutic pencil beam scanning they are suitable candidates for mail auditing in proton therapy. The response of luminescence detector systems have shown promises even though more careful calibration and corrections are needed for its implementation as part of a mailed dosimetry audit system.

Out-of-field doses for scanning proton radiotherapy of shallowly located paediatric tumours-a comparison of range shifter and 3D printed compensator

The lowest possible energy of proton scanning beam in cyclotron proton therapy facilities is typically between 60 and 100 MeV. Treatment of superficial lesions requires a pre-absorber to deliver doses to shallower volumes. In most of the cases a range shifter (RS) is used, but as an alternative solution, a patient-specific 3D printed proton beam compensator (BC) can be applied. A BC enables further reduction of the air gap and consequently reduction of beam scattering. Such pre-absorbers are additional sources of secondary radiation. The aim of this work was the comparison of RS and BC with respect to out-of-field doses for a simulated treatment of superficial paediatric brain tumours. EURADOS WG9 performed comparative measurements of scattered radiation in the Proteus C-235 IBA facility (Cyclotron Centre Bronowice at the Institute of Nuclear Physics, CCB IFJ PAN, Kraków, Poland) using two anthropomorphic phantoms-5 and 10 yr old-for a superficial target in the brain. Both active detectors located inside the therapy room, and passive detectors placed inside the phantoms were used. Measurements were supplemented by Monte Carlo simulation of the radiation transport. For the applied 3D printed pre-absorbers, out-of-field doses from both secondary photons and neutrons were lower than for RS. Measurements with active environmental dosimeters at five positions inside the therapy room indicated that the RS/BC ratio of the out-of-field dose was also higher than one, with a maximum of 1.7. Photon dose inside phantoms leads to higher out-of-field doses for RS than BC to almost all organs with the highest RS/BC ratio 12.5 and 13.2 for breasts for 5 and 10 yr old phantoms, respectively. For organs closest to the isocentre such as the thyroid, neutron doses were lower for BC than RS due to neutrons moderation in the target volume, but for more distant organs like bladder-conversely-lower doses for RS than BC were observed. The use of 3D printed BC as the pre-absorber placed in the near vicinity of patient in the treatment of superficial tumours does not result in the increase of secondary radiation compared to the treatment with RS, placed far from the patient.

Community based medical education – specific needs of elderly population

Background

Many countries in the world are facing problem of population ageing. As a part of medical education regarding that matter, The Community Health Course, based on line that main fields of work for physicians are communities, not physician's consulting rooms, has been conducted at School of Medicine University of Zagreb.

Objectives

Students of last (sixth) year of study attend The Course through one week in rural and semi-urban areas of Croatia. They have insight in living conditions and needs of elderly population trough participation in work with community nurses, family doctors/general practitioners and gerontology house helpers. Students evaluate activities by anonymous questionnaire, giving a grade (from one-very bad to five-outstanding) and writing a short description of experience. For the purpose of this paper we analysed student's evaluation from academic year 2018./19.

Results

Very good and outstanding found 94% of students (N = 299) work with community nurse, 92% with gerontology helpers and 87% with physicians. The value of activities they described as: “ we got an insight into functioning and organization of healthcare outside clinical hospital centres and Zagreb, we entered homes of people and saw how and in what conditions they live”, “being able to participate in work with gerontology helpers and community nurses, first-hand learning, we learned a lot about community”, “extremely valuable insight into lives of people in very difficult life situations and evidenced value of gerontology home helpers”, “I saw differences of living conditions and health care between countryside and city”.

Conclusions

The results of evaluation showed students recognition of importance community oriented medical education, emphasising awareness about specific needs of elderly population.

Key messages

Community oriented medical education could motivate students to choose work in countryside areas in future carriers. Students recognized importance of community oriented medical education, emphasising awareness about specific needs of elderly population.

Project on monitoring persistence of body mass index of school aged children

Issue

Childhood obesity is one of the most important public health issues today. In Croatia every third school aged child are overweight. Monitoring of nutritional status of school aged children in Croatia is a part of routine health examinations provided by School health service, while Project on tracking BMI from early school aged to adolescence provided insight into the risk of overweight in adolescence. Risk assessment for overweight is important in planning interventions in Croatia, as well in other countries.

Description of the Problem

Objective of the project was to collect and analyze anthropometric data of representative sample of Croatian school aged children, to determine tracking of BMI from early school age to adolescence and to assess the risk for overweight in adolescence. Longitudinal follow up included period from first to eight grade of primary school. Data of date of birth, body weight and height were obtained from medical records, and BMI was evaluate according to the national reference values.

Results

Project included 641 participant (49.8% girls) with the data of three measurements within health examination in primary school. Normal weight in all free measurements were 226 (71%, CI95% 66-76%) girls, and 192 (60%, CI95% 54-65%) boys, while overweight were 18 (6%, CI95% 4-9%) girls and 26 boys (8%, CI95% 5-12%), respectively. Probabilities of being overweight in eight grade for girls and boys normal weight in first grade were 10% (CI95% 7-14%) and 13% (CI95% 10-18%), while for overweight in first grade probabilities were 63% (CI95% 46-78%) and 69% (CI95% 54-81%), respectively. Risk of being overweight in eighth grade started increasing at 75th BMI centile value in first grade.

Lessons

Project showed importance of monitoring persistence of BMI of school age children. Intervention should target normal weight children as well, in order to maintain normal weight during the lifespan.

Key messages

Monitoring of nutritional status and risk assessment for overweight is important in planning interventions. Intervention should target not only overweight children, but normal weight children as well.

Adolescent mental health: analysis using YP-CORE test in School health services in Croatia

Issue

Adolescent mental health problems are a leading health problem in this population and remain unrecognized for a long time. The aim of this study was to examine the mental health problems with YP-CORE test as a part of regular school health periodic examination of first-year secondary school students (ages 15-16).

Description of Problem

Study included 392 first-year Zagreb secondary school students (74.5% girls) academic year 2019/2020. Data were collected by YP-CORE test ten questions about feeling over the last week. The students provided informed consent, and testing was done during regular periodic examinations. Data were analyzed using descriptive statistics.

Results

At risk of mental health problems were 7.5% of girls (22/292) and 2.0% of boys. Nine girls (3.1%) had a low overall score, ≤ 19 points, which would mean little risk but had a positive answer to the question 'I've thought of hurting myself'. Ten girls (3.3%) had a score of ≥ 20, which meant an increased risk and a particularly positive answer was the 'I've thought of hurting myself' question. Three girls (1%) had a score of ≥ 20, which meant an increased risk with no additional risk of auto-aggression. The results in the boys are completely different. Two students, 2% (2/100) had a total score of ≥ 17, which meant an increased risk and a particularly positive answer was the 'I've thought of hurting myself' question. All recognized risk students are immediately involved in the counseling of the School and University Medicine Counseling Services provided by every secondary school in Croatia.

Lessons

The results of the study showed that mental health problems have 6.1% secondary school students with gender differences, girls 7.5%, boys 2%. School health service developed a protocol for students at increased risk. The first step is school medicine specialist interview with the student, then with the parents and the student, and second step including school staff and other professionals.

Key messages

Early identification of mental health problems, timely intervention and continuous monitoring of mental health among secondary school students in Croatia. Counseling service for students should be available within the school health service, implementing preventative measures and working closely with other services and professionals.

Sexual behaviour and attitudes among university students in Zagreb

Background

Sexual behaviour of youth could have reproductive health outcomes with an impact on individual and general population health. The aim of this study was to determine sexual behaviour and attitudes among first year university students in city of Zagreb, Croatia.

Methods

Study included 298 first year students (61% of females) of Medical School University of Zagreb and 124 students (75% of females) of Catholic University of Zagreb in academic year 2017/2018. Data were collected by anonymous questionnaire School Health Survey, and analysed by descriptive statistics.

Results

Significantly higher proportion of Catholic University students have had sexual intercourse comparing to medical students of University of Zagreb (48% vs. 36%, P = 0.019). The age of first sexual intercourse for the most of students was from 16-18 years (73% of Catholic University students, and 79% of medical students). Contraception was always used among 54% of Catholic University students, and 67% of medical students, and never used among 11% and 4% of them respectively. Most of the students have gained information about human sexuality from the internet (26% of Catholic University students, and 30% of medical students), followed by friends (18%) and parents (11%) for Catholic University students, and television (25%) and friends (14%) for medical students. Most students expressed the attitude that sex education should be introduced in secondary schools (31% and 36%, respectively), followed by both, in primary and secondary schools (21%, and 30% respectively). Fourteen percent of Catholic University students and 7% of medical students thought that sex education should not be introduced to schools.

Conclusions

Results showed risky sexual behaviour of university students, especially Catholic University students, indicating the need of continuous education on reproductive health among youth.

Key messages

Results indicate the need of intervention and continuous education on reproductive health among university students in Zagreb, Croatia. Results showed insufficient use of contraception especially among Catholic University students indicating the need of education on reproductive health among medical and nonmedical students.

COMPARISON OF RESPONSE OF PASSIVE DOSIMETRY SYSTEMS IN SCANNING PROTON RADIOTHERAPY-A STUDY USING PAEDIATRIC ANTHROPOMORPHIC PHANTOMS

Proton beam therapy has advantages in comparison to conventional photon radiotherapy due to the physical properties of proton beams (e.g. sharp distal fall off, adjustable range and modulation). In proton therapy, there is the possibility of sparing healthy tissue close to the target volume. This is especially important when tumours are located next to critical organs and while treating cancer in paediatric patients. On the other hand, the interactions of protons with matter result in the production of secondary radiation, mostly neutrons and gamma radiation, which deposit their energy at a distance from the target. The aim of this study was to compare the response of different passive dosimetry systems in mixed radiation field induced by proton pencil beam inside anthropomorphic phantoms representing 5 and 10 years old children. Doses were measured in different organs with thermoluminescent (MTS-7, MTS-6 and MCP-N), radiophotoluminescent (GD-352 M and GD-302M), bubble and poly-allyl-diglycol carbonate (PADC) track detectors. Results show that RPL detectors are the less sensitive for neutrons than LiF TLDs and can be applied for in-phantom dosimetry of gamma component. Neutron doses determined using track detectors, bubble detectors and pairs of MTS-7/MTS-6 are consistent within the uncertainty range. This is the first study dealing with measurements on child anthropomorphic phantoms irradiated by a pencil scanning beam technique.

Dose distribution of secondary radiation in a water phantom for a proton pencil beam-EURADOS WG9 intercomparison exercise

Systematic 3D mapping of out-of-field doses induced by a therapeutic proton pencil scanning beam in a 300  ×  300  ×  600 mm³ water phantom was performed using a set of thermoluminescence detectors (TLDs): MTS-7 (⁷LiF:Mg,Ti), MTS-6 (⁶LiF:Mg,Ti), MTS-N (^natLiF:Mg,Ti) and TLD-700 (⁷LiF:Mg,Ti), radiophotoluminescent (RPL) detectors GD-352M and GD-302M, and polyallyldiglycol carbonate (PADC)-based (C₁₂H₁₈O₇) track-etched detectors. Neutron and gamma-ray doses, as well as linear energy transfer distributions, were experimentally determined at 200 points within the phantom. In parallel, the Geant4 Monte Carlo code was applied to calculate neutron and gamma radiation spectra at the position of each detector. For the cubic proton target volume of 100  ×  100  ×  100 mm³ (spread out Bragg peak with a modulation of 100 mm) the scattered photon doses along the main axis of the phantom perpendicular to the primary beam were approximately 0.5 mGy Gy^-1 at a distance of 100 mm and 0.02 mGy Gy^-1 at 300 mm from the center of the target. For the neutrons, the corresponding values of dose equivalent were found to be ~0.7 and ~0.06 mSv Gy^-1, respectively. The measured neutron doses were comparable with the out-of-field neutron doses from a similar experiment with 20 MV x-rays, whereas photon doses for the scanning proton beam were up to three orders of magnitude lower.

Measurement of maximum skin dose in interventional radiology and cardiology and challenges in the set-up of European alert thresholds

To help operators acknowledge patient dose during interventional procedures, EURADOS WG-12 focused on measuring patient skin dose using XR-RV3 gafchromic films, thermoluminescent detector (TLD) pellets or 2D TL foils and on investigating possible correlation to the on-line dose indicators such as fluoroscopy time, Kerma-area product (KAP) and cumulative air Kerma at reference point (CK). The study aims at defining non-centre-specific European alert thresholds for skin dose in three interventional procedures: chemoembolization of the liver (CE), neuroembolization (NE) and percutaneous coronary interventions (PCI). Skin dose values of >3 Gy (ICRP threshold for skin injuries) were indeed measured in these procedures confirming the need for dose indicators that correlate with maximum skin dose (MSD). However, although MSD showed fairly good correlation with KAP and CK, several limitations were identified challenging the set-up of non-centre-specific European alert thresholds. This paper presents preliminary results of this wide European measurement campaign and focuses on the main challenges in the definition of European alert thresholds.

Does morphology of carotid plaque depend on patient's oxidative stress?

OBJECTIVES

This study explored the relationship between oxidative stress biomarkers and stability of carotid plaque. We decided to analyze the broad range of parameters describing oxidative stress in patients with carotid stenosis.

DESIGN AND METHODS

124 consecutive patients undergoing carotid endarterectomy were enrolled in the study group. The control group consisted of 49 patients without symptoms of atherosclerosis. The stability of carotid plaques was assessed using GSM (gray-scale median) scoring system and the study group was divided into three subgroups according to echogenicity of the plaque. The following parameters of oxidative stress/DNA damage were analyzed: i) urinary excretion of the products of oxidative DNA damage repair; ii) the background level of 8-oxo-7,8-dihydro-2'-deoxyguanosine in leukocytes' DNA and in atherosclerotic plaques; and iii) the concentrations of antioxidant vitamins, uric acid and C-reactive protein in plasma.

RESULTS

Oxidative stress (described by redox status) was higher in the patient group than in the control group. There is a correlation between oxidative stress of the patients and stability of the plaque, echolucent plaques (GSM<25) being associated with the highest antioxidant level and lowest excretion of DNA repair markers.

CONCLUSIONS

The plaque formation/morphology may depend on local environment and is independent of oxidative stress/inflammation observed on the level of the whole body.

Improvement in health-related quality of life after therapy with omeprazole in patients with coronary artery disease and recurrent angina-like chest pain. A double-blind, placebo-controlled trial of the SF-36 survey

Background

Many patients with coronary artery disease (CAD) have overlapping gastroenterological causes of recurrent chest pain, mainly due to gastroesophageal reflux (GER) and aspirin-induced gastrointestinal tract damage. These symptoms can be alleviated by proton pump inhibitors (PPIs). The study addressed whether omeprazole treatment also affects general health-related quality of life (HRQL) in patients with CAD.

Study

48 patients with more than 50% narrowing of the coronary arteries on angiography without clinically overt gastrointestinal symptoms were studied. In a double-blind, placebo-controlled, cross-over study design, patients were randomized to take omeprazole 20 mg bid or a placebo for two weeks, and then crossed over to the other study arm. The SF-36 questionnaire was completed before treatment and again after two weeks of therapy.

Results

Patients treated with omeprazole in comparison to the subjects taking the placebo had significantly greater values for the SF-36 survey (which relates to both physical and mental health), as well as for bodily pain, general health perception, and physical health. In comparison to the baseline values, therapy with omeprazole led to a significant increase in the three summarized health components: total SF-36; physical and mental health; and in the following detailed health concept scores: physical functioning, limitations due to physical health problems, bodily pain and emotional well-being.

Conclusions

A double dose of omeprazole improved the general HRQL in patients with CAD without severe gastrointestinal symptoms more effectively than the placebo.

Treatment with double dose of omeprazole increases β-endorphin plasma level in patients with coronary artery disease

INTRODUCTION

The proton pump inhibitor empirical trial, besides the analysis of symptoms, is the main method in the diagnosis of gastro-oesophageal reflux disease-related chest pain. β-Endorphin acts as an endogenous analgesia system. The aim of the study was verify whether β-endorphin plasma level is affected by omeprazole administration and influences the severity of anginal symptoms and outcome of the "omeprazole test" in patients with coronary artery disease (CAD) and chest pain of suspected non-cardiac origin.

MATERIAL AND METHODS

Omeprazole was administered to 48 patients with CAD in a randomized, placebo-controlled, crossover study design. At the beginning of the study, and again after the 14-day omeprazole and placebo treatment, the β-endorphin plasma concentration was determined.

RESULTS

The level of plasma β-endorphin after the administration of omeprazole was significantly greater than at the start of the study and following the placebo. Responders to omeprazole had an average lower β-endorphin plasma concentration than subjects who failed to respond to this therapy. Subjects with symptoms in class III (according to the Canadian Cardiovascular Society classification) after omeprazole administration had a greater β-endorphin plasma level than subjects in class II for anginal symptom severity.

CONCLUSIONS

Fourteen-day therapy with a double omeprazole dose significantly increases the β-endorphin plasma concentration in patients with CAD. Circulating β-endorphin does not seem to be involved in the mechanism for the "omeprazole test" outcome, although an individually different effect on pain threshold cannot be excluded.

[Pheochromocytoma--a disease which is worth to keep in mind]

The case of 25 years old male patient with symptoms of hypertensive storm in the course of pheochromocytoma was presented. For some years he had been suffering from moderate increase in arterial blood pressure whose secondary cause was not suspected by physicians examining this patient. In presented case the course of pheochromocytoma has special characteristics, such as: clinical presentation in young age, the course alternate between periods of hypertension and phases of normal blood pressure, physical signs of Marfan's syndrome, increase of troponin level within hypertensive storm, and attributes of malignant hypertension presented as transient proteinuria and glycosuria within normoglycemia.

HPA-axis regulation at in-patient admission is associated with antidepressant therapy outcome in male but not in female depressed patients

A concatenation of data implicates a hyperactivity of the hypothalamus pituitary adrenal (HPA)-axis in the pathogenesis of depression and its normalization as a necessary predecessor of clinical response to antidepressant drugs. In addition, regulation of the HPA-axis has been shown to be dependent on sex hormones. We therefore investigated gender differences in HPA-axis regulation in depression and its normalization during remission of clinical symptoms. We used the combined dexamethasone suppression/CRH stimulation (Dex-CRH) test to evaluate the degree of HPA-axis dysregulation in 194 in-patients with unipolar depression from the Munich Antidepressant Response Signature (MARS) study at both admission and discharge. The Hamilton Depression (HAM-D) Rating Scale was used to monitor clinical response to antidepressant treatment. For both genders, we observed a normalization of HPA-axis dysregulation in remitters but not in non-remitters, both after 5 weeks of treatment and at discharge. The pattern of HPA-axis normalization with remission of depressive symptoms, however, showed gender-specific differences. In male patients, remission after 5 weeks of in-patient treatment was associated with a significantly higher cortisol response in the Dex-CRH test at admission. In female patients, 5-week remitters and non-remitters had a comparable cortisol response at admission. Cortisol response at admission was not correlated with gonadal steroid levels at this time point and the results were similar for pre-menopausal women vs. post-menopausal women. Gender-associated biological characteristics, likely independent of circulating gonadal steroids, thus seem to influence HPA-axis regulation in depression. In male patients, a single measure of HPA-axis dysregulation at admission may serve as a predictor of response to antidepressant treatment in addition to the previously reported repeated measure of the Dex-CRH test.

The effect of double dose of omeprazole on the course of angina pectoris and treadmill stress test in patients with coronary artery disease--a randomised, double-blind, placebo controlled, crossover trial

BACKGROUND

Gastroesophageal reflux (GER) and coronary artery disease (CAD) frequently overlap, making the proper diagnosis of chest pain more difficult. GER symptoms may mistake anginal chest pain, and oesophageal acidification may induce myocardial ischaemia both in the rest and in the effort. Increase of oesophageal pH should prevent these conditions.

AIM

To estimate the effect of double omeprazole dose on the course of angina pectoris and treadmill stress test in patients with coronary artery disease (CAD), using double-blind, crossover randomised, placebo-controlled study design.

METHODS

We studied 48 patients with angina pectoris symptoms and significant narrowing of coronary vessels in angiography. After baseline examination and treadmill stress test all subjects were randomised to treat either with omeprazole (20 mg b.i.d.) or placebo for 14 days, using a double-blind, crossover placebo controlled design.

RESULTS

Seventeen (35%) subjects reported more than by half decrease in symptoms severity after omeprazole and 6 (12%) after placebo (p=0,01). Omeprazole significantly decreased the number of chest pain episodes and number of nitroglycerin doses taken in the second week of both study phases, as well as the percentage of subjects with significant decrease of ST interval during the stress test (64% vs. 73%, p<0,05). However majority of other stress test parameters (i.e. test duration, DUKE index) have improved both after omeprazole and placebo administration (by 9-38%).

CONCLUSION

Double dose of omeprazole significantly decreased symptoms severity in 35% of patients with CAD, as well as frequency of some electrocardiographic signs of myocardial ischaemia during stress test.

[Gastroesophageal reflux disease and coronary heart disease--coexistence or interrelationship?]

There is the normal coronary artery appearance in 20-30% of coronarographies, made in patients with chest pain and/or positive noninvasive cardiological tests. The simple explanation of this fact is the presence of diseases which may affect coronary perfusion via mechanism independent to the diameter of main coronary arteries. One of them is gastroesophageal reflux disease (GERD). The presence of GERD symptoms in general population concerns about 30-40% of individuals, while non-physiological reflux is stated in 50-65-85% of patients with coronary heart disease (CHD). That means, that GERD is twice more frequent in patients with CHD than in general population. One explanation of the increased frequency of gastroesophageal reflux appearance in patients with CHD is the adverse effect of drugs used in treatment of cardiological diseases. Morover, one of potential mechanisms explaining the influence of esophagal disturbance on the appearance of coronary hipoperfusion may be their common neurological control of the functions. There are three aspects of it: vagal reflexes (esophageal-cardiac reflex), the disturbances of autonomic nervous system balance and changes in visceral pain perception threshold. Visceral reflex can combine GERD and CHD with mechanism of vicious circle: acid gastroesophageal reflux via vagal reflex may cause coronary hipoperfusion, and the products of anaerobic metabolism of cardiomyocytes may cause relaxation of lower esophagus sphincter, facilitating reflux. Additional mechanism connecting GERD and CHD is inflammation caused by Helicobacter pylori infection. The relationship between digestive tract pathology and evolution, as well as progression and complications of atherosclerosis together with similarity of clinical presentation imply the necessity of precise diagnosis of chest pain causes and caution in interpretation of laboratory examination results.

Impaired divided attention predicts delayed response and risk to relapse in subjects with depressive disorders

BACKGROUND

This study addresses the complex relationship between cognitive function and the course of depression.

METHOD

A sample of patients (n=73) in a depressive episode (major depression or bipolar disorder) was tested with a comprehensive battery of attention and executive tasks at both admission and discharge. In addition, response to pharmacological treatment and remission was assessed with standardized rating scales. Nineteen patients, recovered from depression, were re-investigated 6 months after discharge to determine whether specific cognitive parameters were related to subsequent relapse.

RESULTS

On admission, patients were impaired in almost all cognitive tasks. At discharge, we found a significant reduction in psychopathology, but only marginal cognitive improvements. Non-responders after 4 weeks of antidepressive medication and subjects who did not achieve remission prior to discharge were specifically impaired in divided attention on admission (p < 0.05). In addition, a trend was found for the association between impaired divided attention at discharge and an elevated risk to relapse (p < 0.10).

CONCLUSIONS

We observed generalized cognitive impairment in most cognitive domains in acute depression. Cognitive impairments were still within abnormal ranges at discharge but less distinct. Divided attention performance predicted response to treatment, remission of symptoms, and risk to relapse. Impaired divided attention capacity can be explained either by reduced attentional resources or impaired activation and/or top-down control of attentional resources by the central executive.

Suppression of gastric acid production may improve the course of angina pectoris and the results of treadmill stress test in patients with coronary artery disease

BACKGROUND

Coronary artery disease (CAD) and gastro-esophageal reflux disease (GERD) often coexist in the same patients. The aim of this study was to estimate the effects of gastric acid output suppression with rabeprazole on course of angina pectoris and results of the treadmill stress test in patients with CAD.

MATERIAL/METHODS

We studied 34 patients with stable angina pectoris. In all subjects a medical history, a physical examination, and a stress test were performed at the beginning of the study and after two weeks of add-on rabeprazole therapy (20 mg b.i.d.).

RESULTS

Rabeprazole therapy significantly improved the outcome of the stress test in 27 patients (79%), prolonging mean stress exercise time (449+/-147 vs. 489+/-156s, p=0.027) and exercise time, leading to a maximum ST interval depression (360+/-167 vs. 467+/-148s, p=0.001), and also decreasing ST interval depression delta (1.9+/-1.1 vs. 1.5+/-0.9; p=0.013).

CONCLUSIONS

In 79% of our study subjects, rabeprazole improved stress test results in CAD patients, which implies that at least some of their symptoms were related to GERD. A proton pump inhibitor exerted a favorable effect on the frequency of angina-like chest pain and the results of the treadmill stress test.

Pharmacological and nonpharmacological factors influencing hypothalamic-pituitary-adrenocortical axis reactivity in acutely depressed psychiatric in-patients, measured by the Dex-CRH test

The most consistent biological findings in patients with depression are abnormalities in the hypothalamic-pituitary-adrenal (HPA)-axis, which can be measured using the combined dexamethasone-suppression/CRH-stimulation (Dex-CRH) test. The reactivity of the HPA-axis in this test, however, ranges over several orders of magnitude in depressed patients with comparable severity of symptoms. In this present study, we investigate which factors influence the magnitude of the response in the Dex-CRH test in 235 acutely depressed in-patients. We first examined the effects of common confounders shown to influence the HPA-axis, such as caffeine and nicotine consumption, acute stressors during the test, weight, gender, and age. Of all these variables, only female sex and nicotine consumption were positively correlated with the cortisol or ACTH response, respectively. As for the effects of psychopharmacological treatment, only the intake of carbamazepine and the fact of having relapsed under an established pharmacotherapy significantly increased the response in the Dex-CRH test, whereas the presence or absence of antidepressant treatment, the type of antidepressant treatment, or the number of ineffective antidepressant treatment trials during the index episode up to admission did not have any effect. We also found a positive correlation of the number of previous episodes, the overall HAM-D score and the severity of somatic/vegetative symptoms with the results in the Dex-CRH test. These results underline that in depressed patients this test is not majorly influenced by disease-unrelated factors. In addition, current antidepressant treatment does not appear to affect test outcome in the absence of clinical response. The influence of the number of previous episodes and relapse under pharmacotherapy suggests that HPA-axis reactivity may be altered by repetitive states of hypercortisolemia or continuous antidepressant treatment. Finally, more severe vegetative symptoms are associated with an enhanced HPA-axis activity.

Recall and recognition in Huntington's disease

We assessed 19 patients with Huntington's disease (HD) at early to moderately advanced stages of their disease using memory tests that investigated verbal and visual recall and recognition. In those tests where identical material was subject to recall and recognition the standardized results (z scores) were lower for recognition. Performance was better with pictorial than with verbal material. While recognition bias and savings scores did not differ significantly from controls, all other recognition parameters did so. This is in contrast to the claim that defective retrieval in HD is greatly enhanced by multiple choice recognition. One major reason for maintaining this assumption was apparently the disregard of false-positive responses. Our results indicate that verbal and visual recognition are impaired in HD, and the notion of a salient deficit of free recall is not supported.

Visually guided exploration in Huntington disease

We compared 24 patients in various stages of Huntington disease (HD) with 26 control patients free from cerebral disorders using a simple visual saccadic tracking test. The two groups were well matched in regard to age, sex, verbal IQ and years of schooling. Test results differed widely. On a time versus error plot, sensitivity (96%) and specificity (100%) were high and the results did not depend on age, education, or disease duration, although an influence of disease stage could be observed. This study shows that a simple saccadic tracking task may be useful in detecting visuomotor disturbances in HD.